RESUMO
La identificación de pacientes en situación de enfermedad crónica avanzada y complejidad, y la fragmentación de cuidados hacia el final de la vida aconsejan trazar un plan terapéutico a largo plazo, congruente con los valores y preferencias de los pacientes, a la vez que con un pronóstico vital y funcional razonables. Disponer de una herramienta de ajuste en la adecuación de la intensidad diagnóstica y terapéutica sería de ayuda en la continuidad de cuidados y podría ser facilitadora de la toma de decisiones en las transiciones y en los cambios dinámicos que presentan los pacientes a medida que se acercan al final del proceso vital
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process
Assuntos
Humanos , Masculino , Feminino , Idoso , Cuidados Paliativos na Terminalidade da Vida/métodos , Múltiplas Afecções Crônicas/epidemiologia , Planejamento Antecipado de Cuidados/organização & administração , Gestão e Planejamento de Terrenos , Diagnóstico da Situação de Saúde , Técnicas de Apoio para a Decisão , Hospitalização/estatística & dados numéricos , Transplante de Órgãos/estatística & dados numéricos , Avaliação Geriátrica/métodosRESUMO
The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.
